Who s afraid of uncrossmatched RBCs?

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1 Who s afraid of uncrossmatched RBCs? Mark Yazer, MD Mark Yazer, MD Associate Professor of Pathology, University of Pittsburgh Assistant Medical Director, Centralized Transfusion Service, Pittsburgh,PA

2 Outline 1. Discuss the ideal timeline for obtaining crossmatched RBCs 2. Understand the components of pre-transfusion testing in the blood bank 3. Appreciate why unexpected antibodies can be a problem 4. Demystify uncrossmatched RBCs 5. Discuss use of trauma packs I have no conflicts to disclose

3 You have decided to order blood 1. You order the RBCs

4 You have decided to order blood 2 The patient is identified phlebotomized and samples 2. The patient is identified, phlebotomized and samples labeled

5 You have decided to order blood 3. The specimen makes its way to the blood bank

6 You have decided to order blood 4. The blood bank performs an ABO type

7 What is an ABO type? Forward type anti A and anti B sera Recipient RBCs Modified from Zarandona and Yazer, CMAJ 2006:305

8 Recipient s plasma What is an ABO type? Reverse type Reagent A and B cells Modified from Zarandona and Yazer, CMAJ 2006:305

9 You have decided to order blood 5. The blood bank performs antibody screen Type complete

10 What is an antibody screen? Expected antibodies: Naturally occurring antibodies against the lacking A or B antigens Unexpected antibodies: Antibodies to other RBC antigens require exposure D C Cr a Wr b Xg a B Vel Jk a O DIIIb E Lua AnWj A Co a IFC

11 What is an antibody screen? Recipient s plasma Reagent cells Modified from Zarandona and Yazer, CMAJ 2006:305

12 What is a crossmatch? Unexpected antibodies or not, all RBCs are crossmatched with the recipient This ensures serological safety Makes an acute hemolytic reaction unlikely If there are no antibodies a computer can be used to select RBCs Computer crossmatch Computer has logic to determine if recipient and potential donor unit are ABO compatible Fast!

13 You have decided to order blood 6. The blood bank electronically crossmatches RBCs Type complete

14 You have decided to order blood 7. Sometime later the RBCs arrive in the ED Type complete

15 So how long does it take to issue RBCs? Specimen processing 5 minutes ABO type 15 minutes Antibody screen 40 minutes Computer crossmatch 5 minutes ~60 minutes

16 Schießt ein tor

17 What if the antibody screen is positive? Called unexpected antibodies Luckily only found in 5-10% of transfused recipients Can also occur in parous females Antibody specificity must be identified Generally RBCs lacking the cognate antigens must be found Cannot use the computer crossmatch Must physically mix recipient s plasma with potential donor RBC units

18 What s the problem with unexpected antibodies? Antibody Incidence of Ab (%) Freq Ag neg white donors (%) K E D 9 15 Le a 7 80 Fy a 5 30 c 5 20 C 4 30 Jk a 4 20 Need 2 units for Recipient with anti K: Screen 3 units Recipient with anti K and E: Screen 4 units Recipient with anti K, E, D: Screen 21 units Tormey CA et al. Transfusion 2008:2069

19 So how long does it take to issue RBCs? Specimen processing 5 minutes ABO type 15 minutes Antibody screen 40 minutes Further Ab investigation Hours Days Serological crossmatch 40 minutes???

20 What s the rush for RBCs? 21 year old male admitted to the ED following a gun shot wound. He is profusely bleeding from his abdomen, hypotensive, and is quickly becoming hypoxic

21 Is an hour too long to wait for RBCs? X X Specimen processing 5 minutes ABO type 15 minutes Antibody screen 40 minutes Computer crossmatch 5 minutes

22 What to do if we can t ABO type the recipient? Issue uncrossmatched RBCs Always group O Avoids immediate, intravascular hemolysis Readily available, often in refrigerators in ED and OR Nothing special about these units Could have been issued to anyone They re just group O

23 Is an hour too long to wait for RBCs? X X X X Specimen processing 5 minutes ABO type 15 minutes Antibody screen 40 minutes Computer X crossmatch 5 minutes

24 What is the risk of using uncrossmatched RBCs? Unexpected antibodies are typically IgG Can also cause immediate hemolysis The risk of unexpected antibodies is directly proportional to the probability that the recipient was exposed to RBCs Saverimuttu J et al. Emergency Medicine 2003:239

25 What is the risk of using uncrossmatched RBCs? Saverimuttu J et al. Emergency Medicine 2003:239

26 What is the risk of using uncrossmatched RBCs? Questions How many recipients had pre-existing antibodies? How many hemolyzed after receipt of uncx RBCs? Dutton RP et al. J Trauma 2005:1445

27 The Pitt experience with uncrossmatched RBCs 187 recipients of at least 1 uncrossmatched RBC 989 uncrossmatched units in total 63% male Mean age: 55 ± 21 Mean number of uncrossmatched thdrbc units: 53± Range 1-24 Units issued to ED 47% OR 24% ICU 24% Medicine, radiology, L&D 5%

28 What is the risk of using uncrossmatched RBCs? 11 1 No antibodies Antibodies: No hemolysis N h l i Antibodies: Hemolysis 175 Risk of hemolysis: 1/187 (0.5%)

29 More experience with uncrossmatched RBCs 262 recipients of uncrossmatched RBCs 17/262 (6.5%) patients had clinically ca ysg significant antibodies Risk of hemolysis: 1/262 (0.4%) Goodell PA et al., AJCP 2010:202 1/187 (0.5%) 12/187 (6.4%) 7/17 were transfused with incompatible RBC units Only 1/7 hemolyzed!

30 Is receipt of uncrossmatched RBCs predictive of outcome? # Recipients D anti-d Actually 2 Overall survival to discharge: 90/161 (56%) Dutton RP et al. J Trauma 2005:1445

31 Why don t more D- recipients make anti-d? 445 D+ units transfused to 98 D- recipients 82% of D+ RBCs issued to ER, OR, ICU or medicine ward Yazer and Triulzi, Transfusion 2007:2197

32

33 Receipt of uncrossmatched RBCs predicted MT requirement 10 RBC units in 24h 6 plasma units in 24h 2 platelet doses in 24h Nunez TC et al. Transfusion 2010:1914

34 Look at the demographics Nunez TC et al. Transfusion 2010:1914

35 Look at the demographics 153 recipients of at least 1 uncrossmatched RBC unit in the ED Ball CG et al. Can J Surg 2011:111

36 Look at the demographics Sicker patients receive more blood Sicker patients have worse outcomes % Mortality Number of uncrossmatched RBCs Ball CG et al. Can J Surg 2011:111

37

38 What is a massive transfusion protocol? A pre-defined set of RBCs, plasma and PLT (± other stuff) Uncrossmatched Ready to issue in minutes from the blood bank Contents variable Contents variable between institutions

39 Does having an MTP improve outcomes? Vanderbilt University Medical Center Expected 3 improvements by implementing an MTP: Increased access to blood products Reduced mortality Decrease overall blood product utilization Aiming to achieve: Plasma:RBC ratio 2:3 (1:1.5, 0.67) PLT:RBC ratio 1:5 Compared outcomes to historical trauma patients who received massive transfusion without MTP Gunter OL et al. J Trauma 2008:527

40 The Vanderbilt University Medical Center MTP Pt with hard to control bleeding admitted to ED MTP activated by ED doc with call to blood bank Plasma:RBC:PLT 10 RBC, 4 AB plasma, 2 SDP sent to ED from BB 4:10:2 Subsequent rounds of blood products include: 6 RBC, 4 plasma, 2 SDP Trauma doctor can terminate MTP at any time 8:16:4 Pl:RBC = 0.5 1:2 rfviia is not included in this protocol Gunter OL et al. J Trauma 2008:527

41 How many patients were in this study? Abstract Text Gunter OL et al. J Trauma 2008:527

42 No difference in 24-hour survival after receipt of TEP Gunter OL et al. J Trauma 2008:527

43 TEP failed to produce desired plasma:rbc ratio Gunter OL et al. J Trauma 2008:527

44 Authors make a series of claims Patients who received plasma:rbc 2:3 (n=64) had significantly improved 30 day survival compared to those that had less plasma 0 Gunter OL et al. J Trauma 2008:527

45 Are these stratifications meaningful? Increasing amounts of plasma Demographics? Gunter OL et al. J Trauma 2008:527

46

47 Does having an MTP improve outcomes? Many of the same authors have another report featuring a very similar cohort of patients & identical MTP Temperature? Base deficit? Hb? Coagulation parameters? TEG Cotton BA et al. J Trauma 2008:1177

48 Perhaps a role for MTP during trauma surgery Surgical blood loss? What about 24 hour survival? Cotton BA et al. J Trauma, 2008:1177

49 Another study of civilian massive transfusion Retrospective study of massive transfusion patients in Atlanta Analyzed use of MTP (n=132) vs. pre-mtp (n=84 historical i controls) No difference in demographics: Age, gender, ISS, mechanism, base deficit Shaz BH et al. Transfusion 2010:493

50 Does the MTP save lives? MTP pre-mtp p 24 hour RBC NS 24 hour plasma 13 8 < hour aplt 2 2 NS 24 hour cryo NS Plasma:RBC < PLT:RBC NS Cryo:RBC NS Shaz BH et al. Transfusion 2010:493

51 NO MTP pre MTP p Survival (%) 24 hour NS 30 days NS LOS (days) ICU NS Hospital NS Shaz BH et al. Transfusion 2010:493

52 Conclusions Most patients don t have unexpected antibodies Crossmatched blood available in about an hour For the few that do, crossmatched blood takes longer Risk of hemolysis to uncrossmatched RBCs low Don t be afraid to use uncrossmatched RBCs Send sample to blood bank ASAP Massive transfusion packs are a good idea Easy access to uncrossmatched RBCs

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